Experience and coping strategies of bowel dysfunction in postoperative patients with rectal cancer: a systematic review of qualitative evidence

Aim Due to the changes of bowel physiological structure and functional disorders after rectal cancer surgery, patients will face many bowel dysfunction for a long time, which will greatly affect their quality of life. The purpose of this review is to integrate the qualitative research on the experience of bowel dysfunction and coping strategies in postoperative patients with rectal cancer. Methods Systematic retrieval of PubMed, EMbase, Cochrane Library, CINAHL, Web of Sciences, PsycINFO, Willey and other databases was carried out by using the method of subject words and keywords. The Critical Appraisal Skill Programme (CASP) Qualitative Studies Checklist was used for Qualitative assessment. The findings were extracted from the included study and synthesized into the final themes, which was evaluated strictly in accordance with the ConQual process. Results Nine studies involving 345 participants were included and two main themes were extracted: “Experience a series of changes caused by bowel dysfunction” and “nmet needs and coping strategies facing bowel dysfunction”. The changes of rectal cancer patients who experience bowel dysfunction after operation mainly include three parts: bowel dysfunction is more than just a bowel reaction, which covers the bowel symptoms themselves and the subsequent body-related symptoms. The interruption of a normal life, mainly reflected in personal, family, and social life. Complex psychological reactions to bowel dysfunction, psychological changes have a dual nature, showing a positive and negative intertwined. There are two main aspects of unmet needs and coping strategies: the demand is mainly manifested in the need for information and support from medical professionals, while the coping strategy mainly includes diet, activity and drug management. Conclusion Rectal cancer patient often experience persistent bowel dysfunction after operation, which has a certain physical and mental effects. A series of new needs of postoperative patients are often not fully met, and patients often rely on their own empirical attempts to seek balance, less can get professional support. Future studies need to focus on how to provide continuous information support for postoperative rectal cancer patients, especially professional care from health care staff.


INTRODUCTION
Rectal cancer is a common malignant tumor in the world, which brings a huge cancer burden to global health (Bray et al., 2018). By 2020, rectal cancer was the third most common cancer, accounting for 10% of the estimated new cancers worldwide, and cancer-related deaths ranked second (9.4%) (Sung et al., 2021). Surgery is the cornerstone of curative treatment, so surgery has become the main way of radical treatment of rectal cancer, And the main treatment method of early colorectal cancer is surgical resection, including fiber electronic endoscopic resection, local resection and local colorectal resection (Dekker et al., 2019). The location and size of rectal tumor growth affect whether the anal sphincter can be preserved. In the past, many patients often need to remove the sphincter and perform permanent colostomy. With the rapid development of low colorectal diagnosis and treatment and bowel anastomosis, the current focus is on the technique of preserving sphincter and avoiding permanent colostomy (Rouanet et al., 2021). Anterior resection with sphincter preservation has become the gold standard for the treatment of rectal cancer (Inoue & Kusunoki, 2010).
The therapeutic effect of rectal cancer has been significantly improved, and the five-year survival rate of patients has reached 64% (Miller et al., 2019). However, patients often experience persistent bowel symptoms and dysfunction after surgery (Rutherford et al., 2020). Studies have shown that 90% of postoperative rectal cancer patients and nearly 20-50% of rectal cancer postoperative survivors report varying degrees of bowel dysfunction, such as changes in defecation characteristics, urgent defecation, increased defecation frequency, difficulty in emptying, fecal or urinal incontinence, repeated defecation pain, etc (Ziv et al., 2013;Juul et al., 2014;Annicchiarico et al., 2021). Bowel dysfunction after rectal resection and reconstruction is traditionally known as low anterior resection syndrome. These symptoms may improve over time, reaching a stable state after about one to two years, or maybe longer (Reinwalds, Blixter & Carlsson, 2018).
With the development of modern medical model, the outcome evaluation of cancer patients is not only the cure rate and survival rate, but also the physical and mental experience (Firkins et al., 2020). Postoperative bowel dysfunction has the characteristics of unpredictability and long cycle of treatment and recovery, which greatly affects the quality of life of patients (Cabilan & Hines, 2017;Qaderi et al., 2021). In view of the privacy of bowel symptoms, many patients may not be willing to ask initiatives for help. A survey of 101 rectal cancer patients who underwent sphincter sparing surgery found that 71.3% reported changes in defecation habits after surgery, but less than 50% of patients actively reported symptoms (Nikoletti et al., 2008). Rectal cancer experts are different from patients in understanding the symptoms of bowel dysfunction, as they underestimate the impact of the aggregation and urgency of bowel symptoms (Chen, Emmertsen & Laurberg, 2014;Desnoo, 2006).
The changes of bowel function have a great impact on the daily life and psychosocial status of patients (Lu, Huang & Chen, 2017). Early postoperative patients experience pain and vulnerability due to significant changes in bowel function, and often adopt conservative strategies due to poor symptom management (Taylor & Bradshaw, 2013). The treatment of bowel symptoms often depends mainly on patients' self-management, which were often based on their own repeated attempts and lack understanding of the occurrence and evolution of symptoms (Landers, Mccarthy & Savage, 2012). Pape et al. (2021) found that active follow-up nursing strategies are important for the management of bowel symptoms. In recent years, some researchers have begun to pay attention to the diet management (Liu et al., 2021b). Healthy diet programs tend to lead to better physical and role function and less fatigue (Kenkhuis et al., 2021). Patients with or without an ostomy were found to undergo a large number of persistent adjustments, and it was difficult to find a modulated management strategy due to the unpredictability of bowel function (Sun et al., 2015). Liu et al. (2021a) pointed out the necessity of systematic, scientific and continuous guidance of dietary behavior, as well as the management strategies and emotional support. Van der Heijden et al. (2018) proposed measures to strengthen early screening of bowel symptoms and supportive care after discharge.
Although the postoperative bowel symptoms of rectal cancer can be evaluated by objective indicators (Chen, Emmertsen & Laurberg, 2015), individual differences may affect the understanding of intestinal symptoms. Qualitative research is based on in-depth mining of small sample groups to obtain information, the validity and extensibility of single research results are still limited. All aspects of postoperative bowel symptom experience need to be integrated based on multiple qualitative studies to form stronger evidence. Our purpose is to describe the perioperative experience and needs of patients with rectal cancer experiencing bowel dysfunction, and summarize their feelings and responses by integrating relevant qualitative studies. The results of this study can provide a reference for nurses to formulate practical measures to implement bowel function management. For example, it can make nurses pay more attention to the psychological experience and lifestyle of patients after intestinal surgery, and help to tutor family members, especially their spouses, about their emotional changes and sexual life, so that patients can better return to social life and socialization.

METHODS
The purpose of this study was to integrate qualitative research on the experience of bowel dysfunction and coping styles of postoperative patients with rectal cancer. Meta integration is a method to collect, understand, compare, analyze and summarize the results of qualitative research on a particular phenomenon, so as to integrate into a new comprehensive explanation, in order to have a more in-depth understanding of the phenomenon (Sidani, 2008). System and the review protocol was registered in PROSPERO International prospective register of systematic reviews (ID = CRD42021277878).
In addition, the review was produced in accordance with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement (Tong et al., 2012).

Inclusion criteria
Studies that reported the experience and coping with bowel dysfunction after rectal cancer surgery using any of the following qualitative data collection methods (interviews, focus groups, or other responses) were eligible for inclusion. There are no restrictions on research design, qualitative research using phenomenology, grounded theory, descriptive analysis, ethnographic research, action research and other theories as research methods will be included. Studies that are not available in full text or whose data are incomplete, duplicated, or not published in English will be excluded.

Search strategy
The questions in this study include: ''what is the experience of intestinal symptoms in postoperative patients with rectal cancer?'' ''what are the coping strategies for postoperative rectal cancer patients with intestinal symptoms?'' . Based on the above research problems, systematic search is carried out on PubMed, Embase, Cochrane Library, CINAHL, web of Sciences, PsycINFO and Wiley databases. The retrieval time is from the time of building the database to October 2021. The following subject words and keywords were used: ''rectal cancer'', ''intestinal symptoms'', ''patient experience'' and ''qualitative study''. The references in the study were also evaluated to ensure that all relevant studies were included, and the search procedure is shown in Fig. 1.

Study selection
Import the research retrieved from each database into NoteExpress and delete the duplicate studies. Two researchers (WL and DX) who had received evidence-based training and learning conducted literature retrieval independently, excluding articles that irrelevant with the subject. Two researchers independently read and analyzed the topics and abstracts, traced the references, and again excluded the literature that did not meet the inclusion criteria. If there are differences in the process of study extraction, the third researcher (JZ) will assist in the review to reach a consensus. After the initial screening, the methodological quality of the remaining studies was evaluated, the full text of the included study was obtained, and the included study was finally determined. Figure 1 illustrates the search and screening process

Assessment of methodological quality
The literature quality was evaluated independently by two researchers (WL and DX), and the third researcher (JZ) decided if there were any differences. In order to ensure the quality of the research results, all selected papers were methodologically evaluated using the Critical Appraisal Skill Programme (CASP) Qualitative Studies Checklist (CASP, 2017) to ensure that they reported all the relevant details of their methodology and analytical methods. All items in the list are listed as ''Yes '', ''No'' or ''unclear''. All items on the list were excluded as poorly rated studies because they did not meet the predetermined eligibility criteria. Studies rated B level or above were included and are reflected in the results and conclusions of this review by extracting and synthesizing the findings. A total of 9 studies were included in this systematic review, all of which were rated as B level. The main weakness of these studies lies in the absent a clear description of the positioning of researchers and their impact on participants. In-depth discussion of participants' ideas and views in culture or values is insufficient. In addition, the discussion based on theory and philosophy is also lacking. The results of literature quality evaluation are shown in Table 1.

Data abstraction and analysis
Qualitative data are extracted by two independent examiners (WL and DX) using a unified standardized data extraction format and imported into EXCEL for collation. The extracted data include year, country, research design, participants, phenomena of interest and main results in Table 2. The analysis and collation of qualitative data includes three steps. In the first step, after careful reading and study, the main categories and topics are extracted by two researchers. Each finding was independently evaluated by two researchers, and all findings were categorized into one of the following classifications: unequivocal (evidence beyond reasonable doubt); credible (contains illustrations that may be challenged); or unsupported (when findings are not supported) (Table 3) (Munn et al., 2014). The second Table 1 Methodological quality of included studies (n = 9).
Notes. N, no; U, unclear; Y, yes; Y, yes, indicates a clear statement appears in the paper which directly answers the question.; N, no, indicates the question has been directly answered in the negative in the paper.; U, unclear indicates there is on clear statement in the paper that answers the question or there is ambiguous information presented in the paper. Critical appraisal questions for qualitative studies: 1, Is there congruity between the stated philosophical perspective and the research question or methodology? 2, Is there congruity between the research methodology and the research question or objectives? 3, Is there congruity between the research methodology and the methods used to collect data? 4, Is there congruity between the research methodology and the representation and analysis of data? 5, Is there congruity between the research methodology and the interpretation of results? 6, Is there a statement locating the researcher culturally or theoretically? 7, Is the influence of the researcher on the research, and vice-versa, addressed? 8, Are participants, and their voices, adequately represented? 9, Is the research ethical according to current criteria or, is there evidence of ethical approval by an appropriate body? 10, Do the conclusions drawn in the research report flow from the analysis, or interpretation of the data?
step is two researchers integrating the results and, if necessary, a third researcher stepping in to reach consensus. The third step is to make a new interpretation of the establishment of new categories and themes.

Assessing certainty in the findings
The final extracted findings were graded using the ConQual method, and the reliability or credibility of each included study was evaluated according to the value and evidence level of the study (Munn et al., 2014), as shown in Table 4. All comprehensive results start with a high score, followed by an assessment of reliability and credibility. If there are problems in terms of reliability or credibility, the findings will be downgraded.

RESULTS
The research included in this study (n = 9) includes four main qualitative research methods: phenomenology, grounded theory, prospective research and descriptive research. These studies were conducted in England (n = 2), Sweden (n = 2), China (n = 2), as well as Ireland, the United States and the Netherlands. This review included 345 postoperative rectal cancer patients and identified two comprehensive findings: experience a series of changes caused by bowel dysfunction and the unmet needs and coping strategies facing bowel dysfunction.

Synthesized finding 1: experience a series of changes caused by bowel dysfunction
The first theme is related to the physical and psychological experience of postoperative patients with rectal cancer. The main concern is the feeling and experience of postoperative   To illuminate what it means to live with a resected rectum due to rectal cancer, after reversal of a temporary loop-ileostomy.
Three themes were identified in this study: (1) Living with uncertainty; (2) Struggling to live with altered bowel function; (3) Preoccupation. Bowel function.

(CASP)
Sweden Explorative qualitative design based on narrative interviews Qualitative content analysis 16 participants included 9 women and 7 men who had undergone surgery for rectal cancer with an anterior resection and received a temporary loop ileostomy One public university hospital and one public county hospital in Sweden.
To describe the first 4 to 6 weeks after reversal of a temporary loop ileostomy due to rectal cancer.
Three themes were identified in this study: (1) Life being controlled by the altered bowel function; (2) Striving to regain control over the bowel; (3) A desire to be normal.

Netherlands Focus group sessions
Inductive content analysis 16 patients (males = 50%) who had treated with a low anterior resection for rectal or distal sigmoid malignancy.
A non-academic Dutch teaching hospital This study aimed to explore the impact of LARS from a patient perspective facilitating the construction of a set of recommendations improving current care stratagems.
Three themes were identified: (1) illness perception; (2) preoperative care; (3) postoperative supportive care.           *Downgraded one level due to common dependability issues across the included primary studies (the majority of studies had no statement locating the researcher and no acknowledgement of their influence on the research). ** Downgraded one level due to a mix of unequivocal and equivocal findings.
intestinal dysfunction in postoperative patients with rectal cancer. The core concepts that make up the theme include: bowel dysfunction more than just a bowel reaction; the interruption of a normal life; and complex psychological reactions to bowel dysfunction.

Category 1.1: bowel dysfunction more than just a bowel reaction
Most participants experienced more than one bowel symptom, the most common of which included fecal incontinence, intestinal urgency, flatulence, diarrhea, constipation, and inadequate evacuation (Reinwalds, Blixter & Carlsson, 2018;Desnoo, 2006;Lu, Huang & Chen, 2017;Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012;Liu et al., 2021a;Van der Heijden et al., 2018;Reinwalds, Blixter & Carlsson, 2017a). And these symptoms have special meaning for different individuals, maybe acute symptoms to some people, and may not be so important to others (Landers, Mccarthy & Savage, 2012). Many participants expressed a sense of helplessness about uncontrollable symptoms, described the sudden onset and disappearance of bowel symptoms, and said it was difficult to find patterns and signs (Landers, Mccarthy & Savage, 2012). However, participants held different views on the urgency of different symptoms (Reinwalds, Blixter & Carlsson, 2017b). Consistent with the fact that most participants experienced bowel dysfunction after surgery, they felt uncertain about the occurrence and development of the symptoms (Reinwalds, Blixter & Carlsson, 2018;Lu, Huang & Chen, 2017;Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012;Reinwalds, Blixter & Carlsson, 2017a). While experiencing bowel symptoms, participants often mention the time characteristics of the symptoms, and the participants often regard the regularity of the occurrence time of the symptoms as the effective control of the symptoms (Lu, Huang & Chen, 2017;Landers, Mccarthy & Savage, 2012;Sun et al., 2015;Reinwalds, Blixter & Carlsson, 2017a). Participants who experienced bowel symptoms day and night tended to express concern about the persistence of the symptoms (Landers, Mccarthy & Savage, 2012). Some participants reported the bowel dysfunction exceeded their preoperative expectations and cognition, often resulting in deeply personal experiences (Reinwalds, Blixter & Carlsson, 2018).
In addition to the discomfort caused by bowel dysfunction, the participants also suffered other physical discomfort in their daily life. Due to a series of chain reactions caused by bowel dysfunction, participants need to go in and out of the toilet frequently and have to interrupt sleep (Lu, Huang & Chen, 2017;Landers, Mccarthy & Savage, 2012). Long-term work and rest disorders lead to lack of energy and fatigue (Landers, Mccarthy & Savage, 2012). In addition, frequent bowel and local skin pain often make participants fear the next time they go to the toilet and lack an effective coping mechanism (Landers, Mccarthy & Savage, 2012). Some participants said that they need to maintain a fixed posture due to symptoms caused by bowel dysfunction, which often leads to low back pain, and when they encounter sudden symptoms (diarrhea), they need to change their posture in a short period of time, changing posture often brings unbearable pain (Reinwalds, Blixter & Carlsson, 2018).

Category 1.2: the interruption of a normal life
It is often difficult for participants to return to a normal pace of life after operation, and bowel symptoms have a destructive effect on daily life (Desnoo, 2006;Lu, Huang & Chen, 2017;Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012). Destructive bowel symptoms lead to disruptions in the normal pace of life, and even the daily plans of participants often depend on toilet habits (Reinwalds, Blixter & Carlsson, 2017a). Because eating is often closely related to intestinal movement, participants tend to spend more time dealing with intestinal events (defecation) after eating. Participants said that time of eating and the type of food needed to be adjusted after operation to reduce interference with daily life (Lu, Huang & Chen, 2017). Some participants said that due to the need for frequent bowel emptying at night, it was difficult to ensure effective rest at night and had to give up work (Reinwalds, Blixter & Carlsson, 2018). In addition, there are some participants trying to find a balance between bowel dysfunction and life by developing plans to deal with unpredictable events, such as setting deadlines and schedule management (Landers, Mccarthy & Savage, 2012).
Bowel dysfunction also affect the family life of participants, they often feel very difficult to carry out normal family life in the initial stage. Some participants also said that family life has improved to some extent with the passage of time, but it is still need spend more time and energy on planning (Reinwalds, Blixter & Carlsson, 2017a). In addition, participants mentioned the modification of household facilities, such as by adding toilets to avoid interference with the family's need to go to the bathroom (Taylor & Bradshaw, 2013). The participants also had different attitudes towards the care and support of their close family members. Some participants said that it takes courage to tell their families about the disease, and they often find it difficult to act (Van der Heijden et al., 2018). Although participants with partners get more support and care to some extent, they may also face difficulties in opening themselves and having conflicts or quarrels. The feelings and experiences of spouses are often ignored (Van der Heijden et al., 2018). Maintain good communication and understanding, to a certain extent, play a positive role in promoting the relationship between husband and wife, receiving psychological counseling may bring some good suggestions (Lu, Huang & Chen, 2017). Sex life is rarely mentioned, and mutual understanding and support between partners is very important (Lu, Huang & Chen, 2017).
The unpredictability of bowel dysfunction can easily embarrass participants in their normal social life, and participants often take evasive measures to avoid possible embarrassment (Landers, Mccarthy & Savage, 2012;Reinwalds, Blixter & Carlsson, 2017a). Participants were afraid of going out to socialize, afraid of sudden intestinal events (Desnoo, 2006;Landers, Mccarthy & Savage, 2012). Participants often feel difficult and embarrassed to talk about bowel problems, often use euphemisms or special pronouns, and are more willing to share with people with similar experiences (Desnoo, 2006). However, some participants said that it was easier to say it than to cover it up, and it was more understandable to others, avoiding the misunderstanding caused by sudden absence due to bowel emergencies ( Van der Heijden et al., 2018). Peer support among participants has a positive impact on social life. Many participants said that peer support was more comforting, especially suggestions from peer support were often helpful (Lu, Huang & Chen, 2017;Liu et al., 2021a;Reinwalds, Blixter & Carlsson, 2017a).

Category 1.3: complex psychological reactions to bowel dysfunction
Although the surgery altered the normal structure of their intestines, some participants viewed the changes in gut patterns as a small price to pay for life rather than a bad thing (Desnoo, 2006;Reinwalds, Blixter & Carlsson, 2017a). Although the participants had a positive attitude towards the recovery of postoperative bowel dysfunction, they realized that their physical condition would never be the same as before the operation, and tried to seek a sense of balance (Landers, Mccarthy & Savage, 2012). When participants describe bowel-related problems, they often pursue the meaning and value of life by adopting a relaxed attitude as a strategy. Some participants gave a new explanation to the sudden intestinal time and reconciled themselves with it by naming it a word such as 'ordinary fibrillation' and 'great fibrillation' (Reinwalds, Blixter & Carlsson, 2017a). Although there is still persistent bowel dysfunction, participants strive to look for signs of improvement or seek affirmation from doctors to strengthen their confidence in a better outcome (Lu, Huang & Chen, 2017). With the passage of time, participants also gradually began to accept bowel dysfunction, the concept changed from negative to acceptance, and even positive response (Reinwalds, Blixter & Carlsson, 2017a). There has been little exploration of culture and spirituality, and only some participants mentioned the support provided by religious belief, expecting miracles despite being diagnosed with advanced cancer (Lu, Huang & Chen, 2017).
Fear, embarrassment, anxiety, and other bad emotions are often associated with the uncertainty of bowel dysfunction. Participants are often prone to negative emotions or even depression after experiencing frequent and severe intestinal symptoms (Taylor & Bradshaw, 2013). Faced with unpredictable and uncontrollable intestinal problems, participants felt lost confidence and even passive avoidance (Landers, Mccarthy & Savage, 2012). In addition, some participants felt difficult to judge whether they are normal or not, which makes them worry about tumor recurrence (Desnoo, 2006). After the operation, the participants may develop new bowel patterns, resulting in a new understanding of the 'normal' and 'abnormal' bowel patterns, and may face contradictory psychology. Many participants expressed adaptation and acceptance to colostomy, but after reversal, patients may feel worse under multiple pressures such as expectations and uncertain bowel function (Taylor & Bradshaw, 2013;Reinwalds, Blixter & Carlsson, 2017a). Some of the participants even expressed regret over the ostomy and even wanted to resume the ostomy after a year or more (Taylor & Bradshaw, 2013;Reinwalds, Blixter & Carlsson, 2017a).

Synthesized finding 2: unmet needs and coping strategies facing bowel dysfunction
The second topic is related to the needs and self-management strategies of rectal cancer postoperative participants to deal with bowel dysfunction. The core is that participants gradually realize the impact of bowel dysfunction after operation, try a variety of selfmanagement programs to achieve a balance between life and bowel dysfunction, and then look forward to returning to normal life. The core concepts that make up the theme include emerging unmet needs and self-management strategy.

Category 2.1: emerging unconsidered unmet demand
Participants often receive a lot of disease-related information before operation, but they pay more attention to the treatment of the disease at this stage. It is difficult to consider the potential problems after operation, and participants do not really get the information they need. For preparation, participants stressed that it was difficult to imagine the impact of postoperative intestinal symptoms on life (Van der Heijden et al., 2018;Reinwalds, Blixter & Carlsson, 2017a). Some of the participants said that despite being given the information beforehand, they still reported more problems than expected after surgery and more problems after discharge (Landers, Mccarthy & Savage, 2012;Van der Heijden et al., 2018). In addition, some participants raised the problem of insufficient preoperative hints and the need for adaptive guidance for rehabilitation training before operation ( Van der Heijden et al., 2018). For some participants who expressed a sense of helplessness, feeling unable to make a judgment or decision, they believed that the decision should be made by the surgeon (Liu et al., 2021a;Van der Heijden et al., 2018). Most of the participants have a strong demand for relevant information after operation, and the participants also have obvious individual preferences for the way of obtaining information (Van der Heijden et al., 2018).
Compared with the period of hospitalization, participants described a feeling of being abandoned and often faced with the problem of access to medical resources after discharge, and it is difficult to obtain effective support from professionals (Reinwalds, Blixter & Carlsson, 2018;Landers, Mccarthy & Savage, 2012;Van der Heijden et al., 2018). After leaving the hospital, participants lack continuous nursing support and are difficult to get professional nursing services, such as colostomy (Reinwalds, Blixter & Carlsson, 2018). Some participants indicated that the inadequate discharge procedure and the long interval between the first follow-up ( Van der Heijden et al., 2018). Furthermore, participants said it was difficult to rely on non-professionals around them and express their expectation of getting support from medical professionals (Van der Heijden et al., 2018). Participants often choose to consult medical staff as much as possible, and some participants say that simple advice from professionals is often very effective (Liu et al., 2021a;Van der Heijden et al., 2018;Reinwalds, Blixter & Carlsson, 2017a). Some participants indicated that their evaluation of their bowel problems was different from that of professionals, and the use of professional assessment tools or checklists was helpful (Van der Heijden et al., 2018).

Category 2.2: self-management strategy
When considering intestinal dysfunction, participants often first attempt to explore the correlation between diet and symptoms, generally dietary adjustments (Reinwalds, Blixter & Carlsson, 2018;Lu, Huang & Chen, 2017;Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012;Sun et al., 2015;Liu et al., 2021a;Van der Heijden et al., 2018;Reinwalds, Blixter & Carlsson, 2017a). Participants tried to find food suitable for their bowel function through constant trial and error, and some participants expressed fear of trying new things (Landers, Mccarthy & Savage, 2012;Liu et al., 2021a). As for the management of eating time, most patients are trying to find a balance (Lu, Huang & Chen, 2017;Sun et al., 2015;Liu et al., 2021a). Participants want to try to coordinate their bowel patterns with the planned schedule and get free eating time as much as possible, but some participants choose more stringent management and eat as little food as possible (Sun et al., 2015). Dietary adjustments may have positive results, but when it is difficult to achieve a balance between diet and bowel symptoms, participants may lose confidence in food choices and often choose not to eat foods (Taylor & Bradshaw, 2013).
Bowel dysfunctions affect the daily activities of participants, and participants have to change their daily exercise patterns. They may take coping measures such as shortening time, changing exercise patterns, receiving physiotherapy, and wearing protective pads to gain a sense of control and security (Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012). Some participants proposed the role of physiotherapy in the control of bowel symptoms and expressed the need for pre-operative contact and understanding (Munn et al., 2014). After constantly adapting to regulate the relationship between daily activities and bowel dysfunctions, participants struggled to find a new balance and found personal coping strategies, such as smaller activities, post-exercise showers or the use of diaper pads (Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012). In addition, some participants expressed positive views on accepting exercise programs such as bio-energy therapy, spirituality, self-belief, and yoga (Landers, Mccarthy & Savage, 2012).
Drugs and related supplements are also often used to help improve bowel dysfunctions, and participants often use drugs tentatively on a doctor's advice or personal experience (Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012;Sun et al., 2015;Liu et al., 2021a). When constipation occurs, although the effect of drugs is slow, it can usually solve the problem better (Landers, Mccarthy & Savage, 2012). However, when suffering from diarrhea, taking antidiarrheal drugs can help participants improve the trouble of frequent defecation to a certain extent, but it takes a certain time to take effect, and the effect may vary (Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012). Many participants had the problem of poor defecation, which was not effective despite following the doctor's instructions for the use of drugs (Sun et al., 2015), and found that it is more effective to try intestinal irrigation (Liu et al., 2021a).

Assessing certainty in the findings
The comprehensive finding of ''Experience a series of changes caused by bowel dysfunction'' has been determined to have a reliability problem, so it has been downgraded by one level. in addition, in addition to clear results, there are also some uncertain results, so the ConQual score has been reduced from high to medium. The comprehensive discovery of ''Unmet needs and coping strategies facing bowel dysfunction'' has the problem of reliability, and it is also found that there is an uncertain part, so its ConQual score is reduced from high to low.

DISCUSSION
This study describes the bowel and physical symptoms and psychological experiences of postoperative patients with rectal cancer through collective integration. Due to the changes of bowel functional symptoms in postoperative patients with rectal cancer, their original personal life, family life and social life have changed. These changes are a long-term phenomenon, patients need to constantly adjust their lifestyle and attitude to adapt, many patients have a series of negative emotions. Many patients will continue to try to help themselves adapt and accept the changes after rectal cancer surgery by taking drugs or changing their diet. But they do not have systematic and professional support to help them adapt to these changes.
Rectal cancer patients often mention the situation of 'survival mode' before surgery. Patients tend to pay more attention to the treatment-related issues, while the bowel changes and related symptoms that may occur after operation are often not in the primary consideration (Van der Heijden et al., 2018). Postoperative rectal cancer patients will have a series of bowel symptoms and physical symptoms, these symptoms will often last for a long time, and even affect the treatment of the patient's disease. The type, frequency and severity of bowel symptoms are affected by diseases, individuals, and other factors. There are certain individual differences, for example, the most disturbing symptom for some patients is diarrhea, while others are constipation or urinary incontinence (Lu, Huang & Chen, 2017;Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012;Reinwalds, Blixter & Carlsson, 2017a). If left untreated, bowel symptoms may cause or increase the pain of patients, and they are unable to return to a normal life (Landers, Mccarthy & Savage, 2012). In addition, mental and psychological factors also play an important role during this period. It is necessary to help patients understand the changes of bowel function after operation as soon as possible, and the lack of relevant understanding may lead to high expectations (Taylor & Morgan, 2011). Given that symptoms caused by bowel dysfunction are often uncertain, it is difficult for patients to tell whether it is ''normal'' or ''abnormal'' and even to worry about tumor recurrence (Desnoo, 2006). At present, a scoring tool has been developed to evaluate bowel function (Emmertsen & Laurberg, 2012), which can help patients identify their bowel symptoms early. Bowel symptoms may be followed by a range of physical symptoms such as fatigue, sleep disturbances, and pain (Lu, Huang & Chen, 2017). The patient's physical symptoms are less mentioned and more focused on local skin problems and pain associated with frequent defecation (Taylor & Bradshaw, 2013;Landers, Mccarthy & Savage, 2012;Van der Heijden et al., 2018). Some patients also mentioned that they had to go to the toilet frequently, resulting in sleep interruption and fatigue (Reinwalds, Blixter & Carlsson, 2018). Annoying bowel symptoms and worsening physical symptoms can also form a vicious circle, making it necessary to provide more comprehensive support strategies to better promote health outcomes.
The life of patients after rectal cancer has undergone tremendous changes. This process is manifested as the interruption of normal life. The change in the patient's personal life is the first to bear the brunt. The original normal living habits have changed, such as having to go to the toilet frequently, wearing dark clothes, using diaper pads, etc (Reinwalds, Blixter & Carlsson, 2018). In social life, they will always worry about the risk of incontinence (Reinwalds, Blixter & Carlsson, 2018). Frequent use of the toilet and unpleasant smells will make patients deliberately stay away from social activities, which will put them in an embarrassing situation. It's worth noting that despite some stigmatized explanations for bowel-related problems, and perhaps because of this, people with similar experiences are more willing to share them with each other (Desnoo, 2006). As the most common caregiver, the partner's importance to the patient's treatment process is self-evident. However, the patient still feels lonely, expressing that it is difficult to open completely, and the caregiver's concerns may also bring pressure (Van der Heijden et al., 2018). The sexual lifestyle of patients after rectal cancer surgery has also changed, which is consistent with our study (Sun et al., 2016). Bowel symptoms greatly interfere with their daily lives, leading to a range of negative emotions, such as fear, depression, and shame. Kuo's research has similar results (Kuo et al., 2015). Negative emotions interact with bowel symptoms, and the uncontrollability of symptoms often leads to more negative behaviors and even unable to get out of the house (Desnoo, 2006). Nevertheless, after experiencing negative emotional struggles, most patients expressed confidence in seeking a balance between life and bowel symptoms (Reinwalds, Blixter & Carlsson, 2018;Desnoo, 2006;Lu, Huang & Chen, 2017;Taylor & Bradshaw, 2013;Reinwalds, Blixter & Carlsson, 2017a). The support of relatives and friends will increase the trust of the person heart, give them comfort ( Van der Heijden et al., 2018). However, during this period, the patients' negative emotions have not received good attention, and there is still a lack of effective support and intervention mechanisms.
Studies have shown that some patients are unsure of the consequences of surgery, confused about the symptoms they experience, and even regret having the surgery (Reinwalds, Blixter & Carlsson, 2018). It's worth thinking about the importance of timing. In the preoperative stage, patients tend to focus on the treatment of the disease, and lack of attention to the possible bowel symptoms after the operation or as an acceptable price (Desnoo, 2006). In addition, continuous information and care support after surgery are also very necessary. For patients with rectal cancer, the postoperative recovery period is a long process, and the real challenge is after discharge. Due to the high threshold to contact the hospital, it is difficult for patients to obtain the support of relevant professional medical staff, and they are prone to anxiety (Van der Heijden et al., 2018). Different expressions have their own advantages and limitations, and require personal preference. For example, for some patients, they prefer face-to-face communication rather than written communication. Furthermore, it is very important for patients to get support and help from professionals. Patients are more willing to trust professional medical staff, whose experiential guidance can sometimes provide great psychological support and help (Liu et al., 2021a;Lu & Huang, 2018). Burch's research (2021) showed that the quality of life of patients after rectal cancer surgery is not high. Pelvic floor muscle function exercise (Sacomori et al., 2021), sacral nerve stimulation (Kuo et al., 2015), biofeedback training (Liu et al., 2019). Which can effectively alleviate patients' bowel symptoms and improve their quality of life, but there are no high-quality studies that show the most appropriate treatment method. This study summarizes how patients after rectal cancer try to use different self-care strategies to deal with bowel symptoms, including functional self-care strategies, activity-related self-care strategies (such as approaching/knowing the location of the toilet), and alternative self-care strategies (such as complementary therapies) and medications (Landers et al., 2014). This provides a reference for other patients to manage bowel symptoms. However, dietary changes are often initiated by patients. It is not yet known whether these dietary changes are suitable and universal. Drug management strategies still lack effective consistent plans, and individual differences are large. Therefore, health care providers should evaluate these strategies and help patients evaluate their effectiveness. Patients with rectal cancer usually have a series of symptoms after surgery, so medical staff need to conduct long-term follow-up, assess the actual situation of patients, and provide targeted guidance strategies.

CONCLUSION
Patients with rectal cancer often experience persistent bowel dysfunctions after surgery, and changes in bowel function have caused tremendous changes. This is accompanied by negative emotional reactions and even a loss of hope for their lives, which seriously affects their quality of life. To find ways to improve bowel dysfunctions, patients will adopt self-care strategies such as diet adjustments, improving activities and use of drugs, but there is still no effective data to prove the rationality and effectiveness of these measures. In addition to the self-regulation of patients, support from family and society is also needed. It is of concern that the professional support provided by health care professionals is consistently highlighted, but further research is needed on how to provide appropriate support services.

ADDITIONAL INFORMATION AND DECLARATIONS Funding
The authors received no funding for this work.